An Episcopal (Anglican) Chaplain in the Saint Luke's Health System of Kansas City, reflecting on work and faith and life. NOTA BENE: my opinions are my own and do not represent the Episcopal Church or the Saint Luke's Health System.

Wednesday, September 09, 2009

Health Care Reform and the American Character: Reacting to the President's Address

All right, let me get down to brass tacks. Yes, I did watch the President’s address to Congress on health care. Some quick thoughts.

First, I was pleased. No, it wasn’t all I might have hoped for. Those who have read here regularly will know that I lean toward a single payer option. However, it was a doctor some years ago who said to me, “Don’t let perfect become the enemy of good.” That is, don’t get so hung up seeking perfection that you don’t do what good you can.

Second, this is clearly more about reforming and regulating insurance than about health care practices. That said, finding money to carve out of existing Medicare and Medicaid spending does have something to do with health care practices. While he didn’t use the words “medical effectiveness,” the thought was there. Now, in fact everyone in practice wants to know what treatments are effective, and among competing treatments which are more effective. I don’t know a doctor or nurse who doesn’t want to provide the most effective care possible.

I also know that this will be a challenge to the pharmaceutical and medical device industries. I think it’s a good challenge. There are those who claim that this is one of those things that will “stifle innovation.” I think that, on the contrary, it will stimulate innovation. Adding a decongestant to an antihistamine and patenting the “new combination” isn’t innovation. Reformulating a 4-hour dose to a 12-hour dose and patenting a “timed-release” dosage isn’t innovation. What we need are a new antihistamine that works in a different way, or a new antibiotic, or a new surgical procedure that uses less blood – these are innovation. Measuring effectiveness, and using first for each patient and in each situation the therapy that has been shown most effective for most folks, will focus our directions for innovation. We will, after all, need alternatives for second-line treatments and for patients with special needs. We just won’t use them except where they’re the justified choice.

Third, we can do it. More to the point, we can afford it. Affording it is a matter of political will, and not of absolute limits. The President put that in perspective when he compared generally the cost of this plan with the costs of the wars in Iraq and Afghanistan, and when he compared it specifically with the tax cuts for the wealthiest under the last Administration.

What makes that hard for some folks is the fear of one change or another on top of our current system. In fact, though, these changes will significantly change the landscape. For example, if we can effectively provide universal access to health care for all citizens, we can also largely eliminate cost shifting, that percentage providers must add to cover unreimbursed care. That, then, will in itself slow cost increases. Slowing cost increases slows what we pay for coverage, both in premiums and taxes. Or, we can realize that we pay for all this care one way or another. If we pay more in taxes and less in premiums, we’re not paying more over all. And if we involve the greatest number of people in the system, both as user but also as contributors – that’s what the employer and personal mandates do – we minimize relatively what each of us individually has to pay over all. The point is that these things are all connected, and improving one aspect has ramifications for all.

Fourth, I am glad the President presented this as a moral challenge. I’m especially glad that he raised as a counterpoint to America’s cult of individualism that other American tradition of concern and support for one’s neighbor. In my childhood community barn-raising and neighbors clearing land together were as much a part of American cultural history – indeed, more – than the ideal of the rugged individualist. I was raised not on the image of the gunslinger but of the volunteers who fought together at King’s Mountain and at New Orleans; on community action and not on individualism. For the better part of a generation politicians have played held up (small “l”) libertarian ideas in ways that played to individual greed, and that divided us into ever more fragmented clusters of “us and them.” They obscured those generations of Americans who knew how to balance “what’s in it for me?” with “We the People.”

So, the speech is over, and tomorrow morning the politics begin again. Please God, the Senators and Representatives will have listened, and will have been moved. Please God – whether they believe in God or not – they will see this as an opportunity to reflect their own characters in ways that support the President’s vision of the American character.

My older friends Jack and Alice want to ask you if you think the public option is a necessity; are co-ops an acceptable alternative. Jack say yes, Alice says no. They both think requiring all to purchase insurance is a must. Frank

I think cooperatives would in principle be a reasonable alternative to a public option. That said, the existing cooperatives that Senator Kent Conrad points to took years to get to the place they are now, and were established in very different insurance markets. A new cooperative will need time to gather both enough members and enough healthcare providers to offer a meaningful alternative. A public option can happen a lot faster, taking advantage of existing provider networks so that the newly insured have decent availability for their care.

That said, I suppose a middle ground might be crafted. That would be public establishment of what would become a mutual insurance company (which is one existing coop model), not unlike a credit union as a banking alternative. Now, whether folks in Washington have that kind of creativity is another question.